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NEW PILOT EXPERIENCE SURVEY & QUALIFICATION WORKSHEETSECTION I – PERSONAL INFORMATIONCAPIDNAME (Last, First MI)PHONEE-MAILUNIT CHARTERUNIT NAMEDATE JOINED CAPTARGET DATESECTION II – AIRMAN QUALIFICATIONSCERTIFICATES/RATINGS/ENDORSEMENTSFLIGHT EXPERIENCE TYPEFLIGHT TIMERECENCY & KIND OF EXPERIENCE165103155400 Private Pilot165103472900 Commercial Pilot171453282400 Airline Transport Pilot169493238500 Instrument Rating165102964900 High Performance Endorsement171453345900 Complex Endorsement152403536400 Multi Engine Airplane Rating152403091900 Flight Instructor – Airplane186113048000 Flight Instructor – Instrument Medical (1st, 2nd, 3rd, BM) 153543302000 Personal/Recreational144913175000 Corporate (91/135)144913111500 Airline (121)144913238500 Military134213492500 Other (explain Sec. IV)TOTAL TIMECheck all that apply. Use Section IV to explain:165103472900 Flown less than 15 hrs in past 12 months171453282400 Flown more than 25 hrs in past 12 months169493238500 Have 10 hours or more in G1000165102964900 Have instructed 10 hours or more in G1000171453345900 Have 10 hours or more in TAA (not G1000)152403536400 Have instructed 10 hours or more in TAA152403091900 Day Current186113048000 Night Current184153168800 Instrument CurrentPICCROSS CTRYFLIGHT REVIEWDATE COMPLETEDMETHOD OF COMPLETION10280653394500123553429000 Flight Review New Certificate10280722603500124103175000 FAA Wings OtherSECTION III – CAP PREREQUISITESHigh Performance AirplanesComplex AirplanesGippsland GA-8G1000 Equipped Airplanes181801968500 No prerequisites116651460500 100 hours total PIC time 114302055500 10 hours PIC and 25 take-offs and landings are in complex airplanes78551460500 Meet CAP High PerformanceNote: SAR/DR ARCHER additional requirements apply but are not necessary for Initial CAPF 557151691000 Documentation Available (describe in Section IV)57151484000 Experience summarization with G1000 aircraft included in remarks (Section IV)SECTION IV – REMARKSINSTRUCTIONS: Provide any additional necessary to help establish a training footprint. For answers in Section II and III that indicate a remarks entry is necessary ensure a detailed response is provided.SECTION V – MENTOR INFORMATIONMENTOR NAME (LAST, FIRST)PRIMARY PHONEALTERNATE PHONEE-MAIL ................
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